Ask Dr P

I have been having issues in the bedroom and I was wondering if this has an effect regarding my post recovery? or is this simply just in my head ? –Sean, New York, NY

ANSWER:

Sean, great question. There are a couple of reasons men have “bedroom issues” following treatment for testicular cancer whether its following their orchiectomy, chemotherapy or a retroperitoneal lymph node dissection.

The first is an organic cause, hypogonadism, which is the medical term for low testosterone levels. While it is not common, some men, even with one good testicle left, can have low testosterone levels that can lead to low energy levels, libido (sexual desire) and occasionally erectile function, which can translate into poor “bedroom performance.” Technically, a fraction of one testicle should produce enough testosterone to give you a beard, erection and chase your partner around the bedroom. Occasionally, surgery, chemotherapy and even testicular cancer itself, can cause suboptimal testosterone levels. Checking an early morning testosterone level with your doctor (testosterone release is cyclic and highest in the early morning) can assess your hormone function.

The second cause has to do with self-confidence. It takes a lot more than an erection to perform well in the bedroom. Comfort, confidence and self-assuredness can all help performance – and the lack of thereof can have negative impacts. Whatever your treatment course was, you are now missing a testicle, have at least one surgical scar and just went through the biggest scare of your life. For most young men, the diagnosis and treatment of testicular cancer is a strong blow to confidence and the sense of invincibility that most young men have. Surviving testicular cancer takes a lot more than just checking labs, CT scans and xrays – it also has to do with resolving the emotional and psychological issues surrounding the disease. For some men, a testicular prosthesis helps them feel more normal. For others, a short course of anti-depressant medication under the supervision of a doctor may help. For some its a tattoo to commemorate their ordeal. In Baltimore, we have regular “Beers, Bros and Balls” events, where testicular cancer survivors can meet, share their stories, common problems and solutions. So finding a group of TC survivors in your area may also help you “recover” from this life-changing diagnosis.

So my advice: First, check a testosterone level. If its abnormal its an easy fix. If its normal it may give you the confidence to “perform well” in the bedroom. Second, I would also connect with a testicular cancer expert and survivors (whether through social media or in person) – it will let you know you are not alone and help you through these issues. A physician can help you navigate the medical side of this and other survivors can help you navigate the rest. Good luck, you will be back to your studly self soon!

QUESTION: Let’s clear the air once and for all Dr.P! What’s the deal with pregnancy tests detecting testicular cancer? – Mr.Ballsy

ANSWER: Testicular cancer is one of the rare cancers that can secrete “tumor markers,” or molecules that can be detected in the blood. The three common tumor markers for testicular cancer are AFP (alpha-fetoprotein), HCG (human chorionic gonadotropin) and LDH (lactate dehydrogenase). You can learn more about each of these tumor markers at: http://urology.jhu.edu/testis/testis_cancer_markers.php.

A recent story on the internet highlighted the story of a young man who was “diagnosed” with testicular cancer by using an over-the-counter pregnancy test. While I don’t know this patient, I’m sure his story is true – I’ve had a few patients in my practice who had a “positive” pregnancy test before coming to see me. However, this young man, Byron Geldard, had doctors in Cambridgeshire, Engand, puzzled when he presented with pain in his side and an uncertain malignancy that had spread around the body.

While it worked in this circumstance, an over-the-counter pregnancy test is not a great test to diagnose testicular cancer. Knowing that testicular cancer would be the most common malignancy in an 18 year-old man and ordering simple blood tests could have also confirmed the diagnosis of testicular cancer in Byron. Since this story has been plastered around the internet and social media, here’s the truth about HCG, pregnancy tests and testicular cancer…

Pregnancy tests work by detecting HCG in the urine – the same protein that can be secreted by some testicular tumors. So, if you have a testicular tumor and it secretes HCG, a home pregnancy test may confirm that diagnosis. However, HCG is only rarely secreted by testicular tumors:

• Only 15% of early-stage seminomas and 20-40% of NSGCT (non-seminomatous germ cell tumors) will secrete HCG.
• Even in cases of advanced (metastatic spread to lymph nodes or other sites) testicular cancer, only about 50% of tumors (seminomas or NSGCT) will secrete HCG.

In addition, HCG levels need to be relatively high to be detected by the over-the-counter urine tests. Some urine pregnancy tests will detect HCG levels of 20 mIU/mL, but most rely on levels >100 mIU/mL. Of the minority of testicular cancer patients whose tumors secrete HCG, many patients will have HCG levels beneath the detecting capability of a home pregnancy test.

Therefore, HCG (and pregnancy tests) are an unreliable screening test for testicular cancer. If you feel an abnormality during testicular self-exam the first thing you NEED TO DO is contact a physician and make an appointment. If the doctor is concerned, an ultrasound (painless) and blood tests (mostly painless) are the next correct steps. If you’re curious while you wait, try a pregnancy test. If it’s positive then you know the diagnosis and find the nearest testicular cancer expert. If the pregnancy test is “negative” that does NOT necessarily mean that you do NOT have testicular cancer. Remember, upwards of 80% of testicular cancers will NOT secrete HCG so do not rely on a home pregnancy test to prove you are cancer free!

QUESTION : When I was diagnosed with Testicular Cancer I was very nervous, and experienced heightened emotions. After leaving the doctor appointment I felt I didn’t get a chance to express myself due to news I had just received. When diagnosed is it ok to get second opinions or look into possible alternative options? I read a lot of different things on the internet but I am thankful for this reliable resource. –Kyle, Salt Lake City, Utah

ANSWER: Thanks for the great question, Kyle. I think its very important to get a second opinion, and more importantly, to get a second opinion from someone who specializes in Testicular Cancer.

First, I recommend all patients with a life-changing diagnosis to get a second opinion. If you had appendicitis or a pneumonia, most physicians can care for that without issue. Even if you like the first doctor you see, a second opinion is definitely warranted for a new cancer diagnosis. In fact, I recommend that most of my new patients to seek a second opinion to make sure they understand all of their options.

Second, Testicular Cancer is a relatively rare disease and not all urologists, medical oncologists and primary care physicians understand the nuances of treatments and their side effects. Consider this:there are approximately 10,000 urologists in the country and an estimated 8,000 men diagnosed with TC each year. Therefore, on average, each urologist sees one TC patient per year. It’s not their fault, but you want to get an opinion from someone who sees a lot of TC patients. Ultimately, you may return to the first urologist (or physician) you saw – and there’s nothing wrong with that either, but you should certainly seek an “expert” opinion.

I am happy to see any new TC patients at Hopkins, but there are many great centers around the country that can help you and we would be happy to point you in the direction of the one closest to you. – Dr. P

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